tv [untitled] June 10, 2012 10:00pm-10:30pm PDT
hello. i'm ivette torres, and welcome to another edition of the road to recovery . today, we'll be talking about research to practice, how science is helping people with mental and substance use disorders. joining us in our panel today are dr. h. wesley clark, director, center for substance abuse treatment, substance abuse and mental health services administration, u.s. department of health and human services, rockville, maryland; dr. thomas mclellan, director, center for substance abuse solutions, philadelphia, pennsylvania; dr. alexandre laudet, director, center for the study of
addictions and recovery, national development and research institutes, incorporated, new york, new york; dr. candace peterson, associate scientist, evaluation shared service, university of wisconsin population health institute, madison, wisconsin. dr. clark, what does research to practice mean and what does it mean for a methodology or a practice to be evidence-based? research to practice is a concept that captures the evolvement in the research community with regard to various aspects of, in this case, substance abuse or mental health care in an effort to increase the ability to positively affect the individual who's affected by it. so, evidence-based, then, is mobilizing administrative, clinical, and research information to enhance the quality of care and the effectiveness of care in order
to produce the best outcomes associated with providing care, so when people present for care they're getting the best care possible. and, tom, in the field, how much of this is going on? what is the percentage of people that actually do evidence-based practice? well, it's a good question. as dr. clark said, nobody can argue that you need more evidence for the things that you do. every parent demands it for treatments for their children. every treatment provider can see that things are working and they really wonder why do we need researchers telling me. and the reason for that is they don't see people who don't show up again. they don't see people who have left treatment and relapsed. that's the kind of stuff that research can inform practice about. but it's equally important for practice to inform research. dr. laudet, why is the dissemination of research
findings to practitioners in the field of behavioral health an issue of concern? it's an issue of concern because, generally speaking, as researchers, we've had a tendency to do this in a one-way street, so that we come into a treatment-we either design an intervention or we come into a treatment organization as experts. we tell them what we're going to do or what they should be doing without really consulting with them in terms of what they need, just like what tom said. it really has to be a two-way street. and so, i think what has happened so far, many times, is there's-it's really two different specialties, if you will, and what the researcher is doing is really not that relevant to what's going on in the field for a variety of reasons. a lot of the clinical trials, for example, have very exclusive criteria, so that the majority of people
that a treatment agency would see are not included. that's the first thing. and also, a lot of these studies that produce the evidence-based are done in a sort of a cocoon environment that doesn't mirror, and then the research findings are reported in scientific studies that nobody reads or very few people read: a) because people don't have the time, b) because we almost purposely use language that nobody understands. so, unfortunately, i think these are key limitations to the real translation of research to practice in the field, and not just in behavioral health. dr. peterson, is that true for prevention as well? yes, i would say it is true for prevention as well. there are people who work in real-world settings who are interested in helping prevent problems from occurring-in this case, substance abuse or mental health issues-and they have a lot of
constraints on their time. they have a lot of constraints on other resources-could be money, could be technology. and, in terms of bringing research to practice, things that are done in a laboratory or academic setting, if you will, sometimes are not readily translatable into real-world settings with those constraints happening and with a variety of audiences that are in a community setting. so, yeah, i think the same is true in the prevention field as well as in the treatment arena. and, tom, in terms of what we are studying, give us a brief overlook of what we are currently studying. i know nida has done a lot of research on the brain and so on and so forth, but what other areas of interest should a patient, for example, be cognizant about?
i think the best way to think about it is the different stages of let us call it the course of addiction from prevention, as candice was talking about, through early intervention, through treatment, through continuing care and, ultimately, recovery. there's an active program of research from the basic through the clinical through the translational in each of those stages. in prevention, community-oriented studies have been undergoing large-scale national trials. family-based studies have also been done. lots of work has gone on in the brief intervention area in medical settings, but, now, increasingly also in schools and private office settings. treatment has had the luxury of having the most research funding for the longest time, so medications, interventions of all types have been going on and
there's been a real burgeoning literature in that field. we're starting to catch up in the continuing care and the recovery areas, but there needs to be more in that area. and, dr. clark, samhsa originally was founded or authorized to really take the science and develop methodologies or evaluate methodologies. how has that been undertaken in recent years? well, what samhsa attempts to do is work in partnership with our colleagues at the national institutes-national institute of mental health, the national institute of drug abuse, the national institute of alcoholism and alcohol abuse, and other nih institutes-and that science that they developed, as was pointed out by dr. laudet, was very rigorous, but translating, as dr. peterson pointed out, into practice is complex. so, using our addiction technology transfer centers,
we need to educate people about the science. we have to influence the behavior when we use our funding to, shall we say, prime the pump, allow community-based organizations, state authorities, county authorities, tribal authorities to explore the implications of the science that's been developed by researchers for community practice because that's what's pointed out. they work brilliantly in the laboratory or an exquisitely controlled study, but doesn't work when generalized to the general community. so, what we want to use our portfolio for is to help facilitate that information sharing, so that we can determine the utility of the science, and so we can provide feedback to the scientific community about whether the refined techniques that they have explored actually can translate when general practitioners, as it were- counselors, psychologists, social workers, psychiatrists and others-are actually doing things with the protocols
that have been developed. and, dr. peterson, what does the family of a person who needs treatment or someone who is looking to get into treatment willingly need to know? well, there's a lot of different ways to approach treatment, and it's important for an individual or a family who's looking for treatment to know that there are different ways to approach it and that there are evidence-based ways to approach treatment. so, they want to look for things that not only are accessible and affordable to them but also something that's going to fit with their needs. if the person is, for example, very motivated, then there are places that they could go where-would
fit that stage of readiness. if the person is not really that aware or doesn't agree that they have a problem, then you might want to-you're going to start at a different stage with that person, so you want to look for something that fits with that person's set of circumstances. were you able to have that flexibility in your own recovery, dr. peterson? well, my own recovery was quite a long time ago, i think about 26 or 27 years ago now. and, i had the good fortune of being able to go and get help from people who really knew what they were doing in terms of working with where i was at to move me along in my own intrinsic motivation to want to get better. so, i was fortunate that that was true at the time. also, when i got treatment, there weren't the limits, in terms of the number of visits that were paid for or
the length of time that i could stay, and that was of great benefit to me. which are a whole other issue in terms of the provision of services. well, when we come back, i want to touch upon the various types of treatment that are available and the research behind it. we'll be right back. [music] samhsa's approach to moving research to practice in the last 20 years has really evolved. i think we understand now that there are, in fact, specific evidence-based practices that work better than other kinds of practices. and so, we are trying to push those. on the other hand, we also understand that there are things that we don't know. so we're also trying to look at the ways that services can teach us something about research and about
the need for evidence. frankly, the best thing we can do is encourage evidence-based thinking so that clinicians use some combination of the research documents-the information that's available out there, as well as their own clinical experience-and frankly, taking into account what the consumer, what the person in recovery and their family is needing at that particular moment. one of the most important things about trying to get information to the field is also getting information back from the field, so collecting data from practitioners, from consumers, anand peers and digesting that data and returning it to the field allows us to make sure the practitioners have a good understanding of their impact and also allows the funders to understand that we are making a positive difference. [music]
important for me to talk about my recovery from substance abuse. if people see me talking about how i recovered, they see other people talking about their recovery, i think it really helps to remove the stigma that's associated with addiction and with mental illness. people can see that it doesn't have to be only this type of person or that type of person or of this age or gender or race or class or what have you. it can be anybody, and anybody can also recover, given the right support. dr. laudet, let's talk a little bit about integrated treatment for persons with co-occurring and substance use disorders.
well, the majority-by which i mean half or more of individuals who have a substance use problem, have a diagnosable mental health disorder and vice versa. and, historically, in the field, up until some 20 or so years ago, individuals who were duly diagnosed who were seeking help for one disorder but had the co-occurring disorder were essentially falling through the cracks because both of the different professions, if you will, which have very different trainings and therapeutic ideologies, were not only not communicating but very often excluding the individuals who had the two problems. and so, most recently-meaning the last two or three decades- integrated treatment has been recommended. it's been implemented. it's been-it's been evaluated as well. and when you think about it, it makes an enormous amount of sense, because, as professionals, whether it's researchers or clinicians, we have the luxury of looking at
the mental health or the substance use disorder, but the affected individual is one person wrestling with both at the same time, and both of these problems are dynamically associated, if you will, so that the improvement in one area will effect improvement or deterioration in the other area. the other thing i would add is that for people with both a mental health issue and a substance use disorder, as you said, in the past, they were treated kind of separately. this one. this one. there was kind of some argument about, well, which came first? we need to address the substance abuse issue before we can make headway on the mental health issue. on the flip side, the mental health practitioners would say, no, we need to address the depression or what have you before we can really make headway on the substance use. and i think what people are really beginning to understand,
especially in the last decade, that they have to be treated at the same time and not just treated at the same time in parallel, but treated at the same time in a very integrated fashion. if you google dual disorder, you will see hypertension and diabetes, but you never hear problems in treating those two disorders. i think the reason is doctors, nurses, pharmacists are educated in both, and, very importantly, the money comes out of the same pot. so, so often there's a separate pot for mental health money and substance abuse money, and it has produced an unnecessary, really divisive conflict in the education and in the delivery of people. yes, and all the way down to the community level where there are demonstration projects to use evidence-based practices in substance abuse or in mental health disorders.
communities get funding from the federal government to do these demonstration projects, but the funds have been-in the past, at least-siloed, so that they could only address one or the other at the same time. i think one of the reasons that the demonstration grants have been separate is because, indeed, the insurance financing has also been separate, and it's an important thing to keep in mind. there's also another issue that we also have to keep in mind that we're addressing with our screening brief intervention referral and treatment. while it is true that the issue co-occurring is the expectation, not the exception, for those who present the treatment, the majority of the people who have substance abuse problems or mental health problems don't present for treatment. so 95 percent of the 20 million people who meet criteria for substance abuse perceive no need for treatment. in other words, they're not in the treatment setting. so, if we look at integrated treatment,
we're looking at people who tend to have more co-occurring, because a larger group of individuals actually don't meet criteria for co-occurring. and so as we approach the treatment of both mental health issues and addiction issues, we have to look at the whole universe and we have to strategize how we're going to deal with that larger universe because we're not going to make the problem of substance abuse disorder go away. and then, the final thing is that there are also community-based issues that are tied to substance abuse disorders that are not true for mental health disorders-criminal justice issues, child welfare issues, which are much more powerful in the addiction arena than in the mental health arena. so, that creates a demand for an alternative pathway, which, from a clinical point of view, is not terribly effective, but that demand is codified, if you will, at the community level. and, we have examples, however, of states that have, indeed, approached the subject in a very novel way, such as connecticut.
shall we talk a little bit about what thomas kirk did and how he was able to bring together-or attempt to bring together the two fields? well, that is happening, and samhsa is endorsing that. but we also have to step back and look at the larger environment, and that is making sure that whoever presents for whatever problem gets those problems addressed, and making sure that we expand the reach of our intervention, so that we're dealing with people at various stages of the problem. if we only wait until individuals' problems are so severe that they have to engage in treatment, they tend to be more complicated. they cost more, and the interventions tend to be more complicated. yeah. so, the whole notion of how you best address this issue is dependent not only on demonstration grants that organizations like samhsa would pursue but also the research that the nih would pursue and some of the services' strategies that ahrq, the agency for healthcare research and quality,
would pursue. so, we all operate together so that we produce the outcomes at the largest society as well as the individual. the real challenge is certainly with the individual who seeks treatment and where he or she presents, but there's also a whole host of issues in terms of policy, and you yourself, i've just noted, funding streams that really also-right, tom? that also need to be addressed. we talk a lot about evidence- based clinical practices. there's certainly a need for them. there's also a crying need for evidence-based policies, policies that take advantage of what we know now that we didn't know 40 years ago when many state and even federal policies were written. insurance is different. the state of the science is different. the population is different, and that's a place that's going to set the occasion for the kind of array of
quality services that people deserve. and, dr. laudet, it's even more challenging, as we are seeing changes in the healthcare reform system and how that's going to play out in terms of how recovery services, in particular, are going to be offered. can you speak a little bit about that? i actually see an enormous amount of promise from the standpoint of delivery recovery support services in the context of healthcare reform as it's written right now, because-well, there's a number of reasons. of course, there's parity and there's also the fact that, according to numbers, of the 32 new million people we'll be ensured 6 or 10 million of them have a behavioral health-either substance use or mental health problem, so that's one part. but when you look at, in addition to that, several of the key points of healthcare reform are extremely consistent with the recovery-oriented systems of care goals and model that
dr. clark and samhsa have been embracing and promoting for many years at samhsa, for example, screening, early intervention. you have person-centered or patient-centered in healthcare reform. you have integrated care, which for healthcare reform is primary and behavioral healthcare, whereas, in samhsa it's mental health and substance use. and then you have the continuum-of-care model, the chronic-care model, which would, in healthcare reform, be evidenced in the so-called patient integrated care health homes for the people on medicare with the definition of medicare being enlarged in 2014. and i really think that the way that healthcare reform is presenting as written right now is extremely friendly to the recovery support services model that i believe should be implemented.
and really, what's going to be lacking, at least from my perspective, is the science base for the recovery, for the need for recovery support services, because whilst there are a lot of federal agencies-ondcp, of course, the department of education and samhsa-the service level that are pushing for recovery support expansion and calling it recovery has to be research-based. we don't have the funding from the nih. but we have practice-based- we have the-yes, but that's not-you know. so- it's not empirical. it's not empirical yet. okay. we're trying. and, for prevention, dr. peterson, are there some similarities? yeah. you know, with healthcare reform, one of the things that i'm really looking forward to is the coverage of screening and brief intervention in primary healthcare or other healthcare settings. i think if you think of going to the doctor 50 years ago and
you weren't typically routinely screened for high blood pressure, for example. now, it's done routinely. i think the same way of thinking about substance use disorders or mental health disorders in that they are something that can be screened for. if detected early, they can be effectively treated. and if you apply this kind of screening universally, then it is-it's a really good avenue for us to catch problems early to get people education or brief intervention or refer them to the help that they need. and when we come back, we're going to continue to look at some other methodologies that are current and new and that we need to know about. we'll be right back. for more information on national recovery month,
to find out how to get involved, or to locate an event near you, visit the recovery month web site at recoverymonth.gov. i had no idea it was going to be so hard. i didn't know what to expect. you hear the stories, but i never took any of it seriously until i found myself here, and then i realized i was going to have to work hard for my recovery. if you or someone you know has a drug or alcohol problem, you are not alone. call 1-800-662-help. recovery was the hardest job i ever had, and the most important. brought to you by the u.s. department of health and human services. [music] universal counseling services as an outpatient,
mental health and substance abuse treatment program. we are at all the local department of social service sites where we do mental health screenings and referral. we're at the various courthouse sites in the city where we do substance abuse assessments and referrals into the community. we're in about 13 different baltimore city public schools, where we provide substance abuse and mental health screening, as well as provide treatment, referral, crisis intervention, and mental health supports for the school system. it get better, you know? right. get better if you work on it, try to keep yourself focused. it is very important that we find out what the individual is requesting, what they're in need of, so that we can better address both other organizations' problems, such as homelessness, hiv, substance abuse co-occurring, and, a lot of times, legal issues are also in need of. i want to thank you for letting me see this second half of
your recovery up until the-you know-golden time of day. so- research to practice is using the research that's been shown to be positive for patient outcomes and applying it to practice. what's your top thing on your addictions list? uh, to keep with the meetings and not slip from them. for a practice to be evidence-based, it would include various models of care that have been tested through research to show positive outcomes. research also offers statistics, and it gives you insight on the demographics of, kind of like the breakdown of how you need to help certain cultures, certain age groups, certain socioeconomic statuses, and i think that's where the research is very effective. when a person comes in for substance abuse treatment, if there is an underlying mental health issue that
it be treated simultaneously. i mean, i have social workers and psychiatrists right across the hall from me. i can't just be comfortable with one approach. substance abuse and mental health, to me, they're best friends, and i always state that in my therapy. you can't really address one without addressing the other. how else will you be able to treat people unless you know what's out there and what resources you can obtain to help them? there's this old stigma that's attached, once an addict, always an addict. and places like this let me know that that's a lie. they don't treat one disease without treating another. it is important that everybody communicates and know and is aware of what the client wants. and in order for them to have a fulfilled recovery process, it is important that everybody is on the same page. you know, when you come in, you try to use your
credentials and what you've learned so far, and your work experience, you know, to an advantage. but, after a while, you can only go so far with that and you have to, you know, just upgrade yourself and polish your styles, accounts, and linear techniques because the population you're serving is different than the one you just came from. my hope for the recovery community is that a reconciliation of science and spirituality, that we learn from what science teaches us about the brain and apply it to the more spiritual principles of recovery which talk about what do we want out of life. and there shouldn't be any reason why these two approaches can't coexist. i wish they didn't get me crying. [laughter] it's real important that they understand that we are all in this process. and if i was able to come out of that process successfully and